In a world of decreasing reimbursements and diminishing
opportunities
in DME, a more advanced approach to airway clearance therapy
is making a resurgence and bringing DME companies a new and exciting
opportunity to do a number of things.
This resurgence is allowing DMEs to leverage a new revenue stream that is
much needed in our industry, and that is providing patients with a different
approach to managing a difficult disease process that is highlighted by shortness
of breath and recurrent lung infections that keep them on and off antibiotics
and much worse in and out of the hospital with exacerbations. It is also
providing physicians a way to keep their patients at a healthier baseline and
probably most importantly it is saving the healthcare system and payers much
needed resources in an increasingly expensive healthcare market. I would
argue that the therapy modalities that can be offered in the airway clearance
market create a win-win dynamic that DME companies and primary care
providers would be smart to take a closer look at.
Some Perspective
For some perspective on how important recent airway clearance advances
have become, let’s first look at some innovations that changed the trajectory
of DME. One of the clear advances was power wheelchairs, which really took
hold in the 1960s after their first forays in the 1950s.
Another key innovation was oxygen concentrators. Prior to the invention of
oxygen concentrators in the 1970’s, therapeutic oxygen was either delivered
via heavy tanks, through small liquid oxygen systems, or it was not readily
available at all. An influx of new DME companies not only benefited financially
thanks to a more efficient way to provide oxygen therapy, but played a big role
in extending the lives of respiratory patients.
Moving forward in the 1980s Dr. Colin Sullivan came up with the idea of
mechanically creating a “pneumatic pressure splint” to keep patient’s airways
open that were collapsing during hours of sleep, and by the mid 1980s CPAP
was born in the U.S. market. Another key development, home ventilation not
only changed the lives of countless patients by creating a higher quality of
life deep into the golden years, it created a revenue stream for and increasing
number of DME businesses all over the country.
With the implementation of the competitive bidding program, we are all
looking for the next power wheelchair, oxygen concentrator or CPAP, and I
believe we have found it in high frequency chest wall oscillation (HFCWO).
Understanding HFCWO
There are two different technologies in delivering HFCWO therapy, pneumatic
using an airbladder vest, or oscillation motors that are incorporated in a vest
using portable battery technology. These two technologies provide two different
pathways in delivering this therapy, airflow or direct oscillation. There
are several manufacturers (such as Hill Rom, Electromed, RespirTech) in the
pneumatic airflow/air bladder style market that focus mostly on pressure and
airflow to mobilize secretions and one (Afflovest), which is the newest technology,
that provides direct motorized oscillation waves in a portable and mobile
during use vest that transmits oscillation waves into the chest and lungs to
mobilize secretions designed to mimic manual hand Chest Physical Therapy
(CPT) performed by RTs which is the gold standard in delivery of this therapy.
Just like any therapeutic intervention one approach will not work for all of
your patients, so be sure to speak with your vendors and partners to decide
what approach will benefit your patient’s most.
The therapies that airway clearance is most frequently ordered can vary in
intensity and effectiveness depending on the diagnoses that are being treated
and the stage of the disease at time of prescription. These include positive
expiratory pressure (PEP) devices such as the Flutter Valve, Acapella, Aerobika
and others that target secretions in larger airways, cough assist devices such
as from Respironics that are helpful with patients who have a diminished
cough effort and High Frequency Chest Wall oscillation (HFCWO) systems
as described above for the more severe diagnoses that require secretion
mobilization and pulmonary clearance in the distal portions of the lung fields
and smaller airways.
The most common diagnoses that are appropriate for these therapies are the
Cystic Fibrosis and Bronchiectasis patient populations. By far bronchiectasis
is the largest population of patients that may benefit from this therapy.
According to lung.org and the CDC there are approximately 15 million, and
as many as 24 million, COPD patients nationwide and approximately 30 to 40
percent of these patients have bronchiectasis. This translates into approximately
5 to 8 million Bronchiectasis patients. As comparison there are about
1.5 million oxygen patients. As these patients progress down to stage 3 and 4
in their COPD disease management path it is very important to verify or rule
out bronchiectasis via high resolution computed tomography (CT). This
might allow these patients an opportunity to decrease antibiotic use,
admissions and readmissions into healthcare facilities that take up a large
portion of Medicare resources.
In addition to bronchiectasis and the cystic fibrosis patient, there are
a number of neuromuscular diagnoses that can benefit from airway
clearance therapy. Amyotrophic Lateral Sclerosis, Multiple Sclerosis,
Muscular dystrophy, Quadriplegia and others have been shown to clinically
benefit from maintaining good management of secretions that create
pulmonary
insufficiencies.
The financial opportunities are both on the cash sales side of the business
in addition to HCPC codes that can be billed to payers on patient’s behalf. At
the lower reimbursement range DME providers are submitting claims for some
PEP devices as low as $100 dollars and on the higher reimbursement side for
high frequency chest wall oscillation devices for as much as $16,000 dollars.
Reimbursement opportunities are going to depend on insurance allowable
amounts and patient’s responsibilities but providers across the board are
seeing good profit margins for most of these modalities ranging from the low
single digits to as much as 50 percent margins.
Be aware that for most of the patients using the more advanced airway
clearance devices, they will need to provide a tried and failed therapy of a less
advanced device as part of the qualification requirement for payments for the
more expensive devices. This allows insurance providers to ensure that
resources are not being spent on very expensive devices when a simple PEP
device will suffice at the time. Insurance providers recognize that these disease
processes are progressive and most of the patients living with these afflictions
will require higher and more intense therapeutic interventions at some point
in their care but a tried and failed requirement does help in maximizing
healthcare dollars.